Section 125.205  Eligibility Exclusions and Terminations

a)         An individual shall not be determined eligible for coverage under the Program if:

1)         The individual is an inmate of a public institution.

2)         The individual is a patient in an institution for mental diseases.

3)         The individual is in categories described in Section 125.200(e)(6) or (e)(7), and the individual entered the United States on or after August 22, 1996; he or she shall not be eligible for five years beginning on the date the individual entered the United States.

b)         Effective July 1, 2012, termination of an individual's coverage under the Program shall be initiated upon the occurrence of any of the following events:

1)         A child becomes ineligible due to:

A)        Losing his or her Illinois residency.

B)        Attaining 19 years of age.

C)        Becoming enrolled in Medical Assistance.

D)        Meeting the provisions of subsection (a)(1) or (a)(3).

2)         Other Events

A)        The required premiums under the All Kids Health Plan are not paid, as specified in Sections 125.320 and 125.330.

B)        The individual fails to report to the Department changes in information that impacts upon the individual's eligibility for the Program.

C)        The individual makes a request to the Department to terminate the coverage.

D)        The Department determines that the individual is no longer eligible based on any other applicable State or federal law or regulation.

E)        The Department determines that the individual failed to provide eligibility information that was truthful and accurate to the best of the applicant's knowledge and belief and that affected the eligibility determination.

F)         There has been a Rebate overpayment and it has not been repaid to the Department according to terms established by the Department.

G)        The Department determines that the individual's eligibility was incorrectly determined.

H)        The application was approved pending receipt of the individual's Social Security Number and it is not provided later when requested.

c)         Following termination of an individual's coverage under the Program, the following action is required before the individual can be re-enrolled:

1)         The individual must be found eligible;

2)         There must be full payment of premiums under the All Kids Health Plan, for periods in which a premium was owed and not paid for the individual, including premiums owed when the individual was, for purposes of this Part, a member of another family;

3)         Any overpayment of Rebates paid on behalf of the individual must be repaid to the Department; and

4)         The first month's premium must be paid if the individual is eligible for All Kids Premium Level 1 if there was an unpaid overdue premium on the date the individual's previous case was canceled.

d)         An application will be denied if any of the adults in the family was responsible as a caretaker relative or was enrolled in FamilyCare Premium during a period for which a premium under the Program was due to the Department and the premium remains unpaid at the time of application.  Such an application shall be denied regardless of whether the individual for whom the premium remains unpaid is included in the application.

e)         An application will be denied if any of the adults in the family was enrolled in FamilyCare Rebate or was a caretaker relative of a child during a period for which a Rebate overpayment was received or was the payee of a Rebate overpayment and the overpayment has not been repaid to the Department.  Such an application shall be denied regardless of whether the individual for whom the Rebate overpayment remains unpaid is included in the application.

f)         A certificate of prior creditable coverage will be issued when the individual's coverage is terminated under the All Kids Health Plan.

(Source:  Amended at 38 Ill. Reg. 6006, effective February 26, 2014)